HL7.FHIR.US.MCODE\Cancer-Related Surgical Procedure

This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v1.16.0: STU 2 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

Resource Profile: Cancer-Related Surgical Procedure

Defining URL:

http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-related-surgical-procedure

Version:

1.16.0

Name:

CancerRelatedSurgicalProcedure

Title:

Cancer-Related Surgical Procedure

Status:

Active as of 2021-04-15T12:44:45+00:00

Definition:

A surgical action addressing a cancer condition. The scope of this profile has been narrowed to cancer-related procedures by constraining the reasonReference and reasonCode to cancer conditions, one of which is required.

Publisher:

HL7 International Clinical Interoperability Council

Source Resource:

XML / JSON / Turtle

The official URL for this profile is:

http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-related-surgical-procedure

Conformance

Procedure resources associated with an mCODE patient with Procedure.category SNOMED CT 387713003 MAY conform to this profile. Beyond this requirement, a producer of resources SHOULD ensure that any resource instance associated with an mCODE patient that would reasonably be expected to conform to this profile SHOULD be published in this form. Specifically, any surgical procedure related to the treatment of a PrimaryCancerCondition or SecondaryCancerCondition SHOULD published in this form.

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

Text Summary
Differential Table
Snapshot Table
Snapshot Table (Must Support)
All

This structure is derived from USCoreProcedureProfile

Summary

Mandatory: 1 element
Must-Support: 7 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

This structure is derived from USCoreProcedureProfile

Name	Flags	Card.	Type	Description & Constraints
Procedure	I	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present
extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
mcode-treatment-intent	S	0..1	CodeableConcept	Treatment Intent URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-intent Binding: Treatment Intent Value Set (required)
category		1..1	CodeableConcept	Classification of the procedure Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
code		1..1	CodeableConcept	Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Cancer-Related Surgical Procedure Value Set (extensible)
reasonCode	S	0..*	CodeableConcept	Coded reason procedure performed Binding: Cancer Disorder Value Set (required)
reasonReference	S	0..*	Reference(Primary Cancer Condition \| Secondary Cancer Condition)	The justification that the procedure was performed
bodySite	S	0..*	CodeableConcept	Target body sites
extension	S	0..*	Extension	Extension
mcode-location-qualifier	S	0..*	CodeableConcept	Location Qualifier URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-location-qualifier Binding: Location Qualifier Value Set (required)
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Procedure	I	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
mcode-treatment-intent	S	0..1	CodeableConcept	Treatment Intent URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-intent Binding: Treatment Intent Value Set (required)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this procedure
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition \| ActivityDefinition \| Measure \| OperationDefinition \| Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan \| ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure \| Observation \| MedicationAdministration)	Part of referenced event
status	?!SΣ	1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown Binding: EventStatus (required)
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	Σ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	SΣ	1..1	CodeableConcept	Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Cancer-Related Surgical Procedure Value Set (extensible)
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣ	1..1		When the procedure was performed
performedDateTime			dateTime
performedPeriod			Period
recorder	Σ	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	Σ	1..1	Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location)	Where the procedure happened
reasonCode	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: Cancer Disorder Value Set (required)
reasonReference	SΣ	0..*	Reference(Primary Cancer Condition \| Secondary Cancer Condition)	The justification that the procedure was performed
bodySite	SΣ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
id		0..1	string	Unique id for inter-element referencing
extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
mcode-location-qualifier	S	0..*	CodeableConcept	Location Qualifier URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-location-qualifier Binding: Location Qualifier Value Set (required)
coding	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	0..1	string	Plain text representation of the concept
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport \| DocumentReference \| Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated		1..1	Reference(Device)	Device that was changed
usedReference		0..*	Reference(Device \| Medication \| Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Procedure	I	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
mcode-treatment-intent		0..1	CodeableConcept	Treatment Intent URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-intent Binding: Treatment Intent Value Set (required)
status	?!Σ	1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown Binding: EventStatus (required)
code	Σ	1..1	CodeableConcept	Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Cancer-Related Surgical Procedure Value Set (extensible)
subject	Σ	1..1	Reference(US Core Patient Profile)	Who the procedure was performed on
performed[x]	Σ	1..1		When the procedure was performed
performedDateTime			dateTime
performedPeriod			Period
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: Cancer Disorder Value Set (required)
reasonReference	Σ	0..*	Reference(Primary Cancer Condition \| Secondary Cancer Condition)	The justification that the procedure was performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
mcode-location-qualifier		0..*	CodeableConcept	Location Qualifier URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-location-qualifier Binding: Location Qualifier Value Set (required)
Documentation for this format

This structure is derived from USCoreProcedureProfile

Summary

Mandatory: 1 element
Must-Support: 7 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from USCoreProcedureProfile

Name	Flags	Card.	Type	Description & Constraints
Procedure	I	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present
extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
mcode-treatment-intent	S	0..1	CodeableConcept	Treatment Intent URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-intent Binding: Treatment Intent Value Set (required)
category		1..1	CodeableConcept	Classification of the procedure Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
code		1..1	CodeableConcept	Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Cancer-Related Surgical Procedure Value Set (extensible)
reasonCode	S	0..*	CodeableConcept	Coded reason procedure performed Binding: Cancer Disorder Value Set (required)
reasonReference	S	0..*	Reference(Primary Cancer Condition \| Secondary Cancer Condition)	The justification that the procedure was performed
bodySite	S	0..*	CodeableConcept	Target body sites
extension	S	0..*	Extension	Extension
mcode-location-qualifier	S	0..*	CodeableConcept	Location Qualifier URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-location-qualifier Binding: Location Qualifier Value Set (required)
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Procedure	I	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
mcode-treatment-intent	S	0..1	CodeableConcept	Treatment Intent URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-intent Binding: Treatment Intent Value Set (required)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this procedure
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition \| ActivityDefinition \| Measure \| OperationDefinition \| Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan \| ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure \| Observation \| MedicationAdministration)	Part of referenced event
status	?!SΣ	1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown Binding: EventStatus (required)
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	Σ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	SΣ	1..1	CodeableConcept	Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Cancer-Related Surgical Procedure Value Set (extensible)
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣ	1..1		When the procedure was performed
performedDateTime			dateTime
performedPeriod			Period
recorder	Σ	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	Σ	1..1	Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location)	Where the procedure happened
reasonCode	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: Cancer Disorder Value Set (required)
reasonReference	SΣ	0..*	Reference(Primary Cancer Condition \| Secondary Cancer Condition)	The justification that the procedure was performed
bodySite	SΣ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
id		0..1	string	Unique id for inter-element referencing
extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
mcode-location-qualifier	S	0..*	CodeableConcept	Location Qualifier URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-location-qualifier Binding: Location Qualifier Value Set (required)
coding	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	0..1	string	Plain text representation of the concept
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport \| DocumentReference \| Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated		1..1	Reference(Device)	Device that was changed
usedReference		0..*	Reference(Device \| Medication \| Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Other representations of profile: Schematron

Terminology Bindings

Path	Conformance	ValueSet / Code
Procedure.language	preferred	CommonLanguages Max Binding: AllLanguages
Procedure.status	required	EventStatus
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT)
Procedure.category	example	Pattern: SNOMED CT code 387713003
Procedure.code	extensible	CancerRelatedSurgicalProcedureVS
Procedure.performer.function	example	ProcedurePerformerRoleCodes
Procedure.reasonCode	required	CancerDisorderVS
Procedure.bodySite	example	SNOMEDCTBodyStructures
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT)
Procedure.complication	example	Condition/Problem/DiagnosisCodes
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes
Procedure.usedCode	example	FHIRDeviceTypes

Constraints

Id	Path	Details	Requirements
mcode-reason-required	Procedure	One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists()